Prevention is the key to staying healthy while travelling in the Middle East. Infectious diseases can and do occur in the region but are usually associated with poor living conditions and poverty and can be avoided with a few precautions. The most common reason for travellers needing medical help is as a result of accidents – cars are not always well maintained, seatbelts are rare and poorly lit roads are littered with potholes. Medical facilities can be excellent in large cities, but in remote areas may be more basic.
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Before You Go
A little planning before departure can save you a lot of trouble later. See your dentist before a long trip; carry a spare pair of contact lenses and glasses (and take your optical prescription); and carry a first-aid kit with you.
It’s tempting to leave it all to the last minute – don’t! Many vaccines don’t ensure immunity until two weeks after treatment, so visit a doctor four to eight weeks before departure. Ask your doctor for an International Certificate of Vaccination (otherwise known as the yellow booklet), which will list all the vaccinations you’ve received. This is mandatory for countries that require proof of yellow fever vaccination upon entry (and you'll need this if you're flying in from sub-Saharan Africa), but it’s a good idea to carry it wherever you travel.
Travellers can register with the International Association for Medical Advice to Travellers (www.iamat.org). Its website can help travellers to find a doctor with recognised training. Those heading off to very remote areas might like to do a first-aid course (Red Cross and St John Ambulance can help).
Bring medications in their original, clearly labelled containers. A signed and dated letter from your physician describing your medical conditions and medications, including generic names, is also a good idea. If carrying syringes or needles, be sure to have a physician’s letter documenting their medical necessity.
Find out in advance if your insurance plan will make payments directly to providers or reimburse you later for overseas health expenditures (in many Middle Eastern countries doctors expect payment in cash). It’s also worth making sure that your travel insurance will cover repatriation home or to better medical facilities elsewhere. Your insurance company may be able to locate the nearest source of medical help, or you can ask at your hotel. In an emergency, contact your embassy or consulate. Your travel insurance will not usually cover you for anything other than emergency dental treatment. Not all insurance covers emergency aeromedical evacuation home or to a hospital in a major city, which may be the only way to get medical attention for a serious emergency.
Following is a list of other items you should consider packing in your medical kit.
- acetaminophen/paracetamol (eg Tylenol) or aspirin
- adhesive or paper tape
- antibacterial ointment (eg Bactroban) for cuts and abrasions
- antibiotics (if travelling off the beaten track)
- antidiarrhoeal drugs (eg containing loperamide)
- antihistamines (for hay fever and allergic reactions)
- anti-inflammatory drugs (eg containing ibuprofen)
- bandages, gauze, gauze rolls
- insect repellent that contains DEET (for skin)
- insect spray that contains permethrin (for clothing, tents and bed nets)
- iodine tablets (for water purification)
- oral-rehydration salts
- pocket knife
- scissors, safety pins, tweezers
- steroid cream or cortisone (for allergic rashes)
- syringes and sterile needles (if travelling to remote areas)
The World Health Organization (WHO) recommends that all travellers, regardless of the region they are travelling in, should be covered for diphtheria, tetanus, measles, mumps, rubella and polio, as well as hepatitis B. While making preparations to travel, take the opportunity to ensure that all of your routine vaccination cover is complete. The consequences of these diseases can be severe and outbreaks do occur in the Middle East.
Travel Health Websites
There is a wealth of travel health advice on the internet. The World Health Organization publishes the helpful International Travel and Health, available free at www.who.int/ith. Other useful websites include MD Travel Health (www.redplanet.travel/mdtravelhealth), Travel Doctor (www.traveldoctor.co.uk) and Fit for Travel (www.fitfortravel.scot.nhs.uk).
Official government travel health websites:
In the Middle East
Availability & Cost of Healthcare
Healthcare systems in the Middle East vary. Medical care can be excellent in Israel, Turkey and Gulf cities, with well-trained doctors and nurses, but can be patchier elsewhere. Reciprocal health arrangements with countries rarely exist, and you should be prepared to pay for all medical and dental treatment.
Medical care is not always readily available outside major cities. Medicine, and even sterile dressings or intravenous fluids, may need to be bought from a local pharmacy. Nursing care may be limited or rudimentary as this is something families and friends are expected to provide.
Standards of dental care are variable throughout the region, and there is an increased risk of hepatitis B and HIV transmission via poorly sterilised equipment.
For minor illnesses such as diarrhoea, pharmacists can often provide valuable advice and sell over-the-counter medication. They can also advise as to whether more specialised help is needed.
Diphtheria is spread through close respiratory contact. It causes a high temperature and severe sore throat. Sometimes a membrane forms across the throat requiring a tracheotomy to prevent suffocation. Vaccination is recommended for those likely to be in close contact with the local population in infected areas. The vaccine is given as an injection alone, or with tetanus, and lasts 10 years.
Hepatitis A is spread through contaminated food (particularly shellfish) and water. It causes jaundice, and although it is rarely fatal, can cause prolonged lethargy and delayed recovery. Symptoms include dark urine, a yellow colour to the whites of the eyes, fever, and abdominal pain. Hepatitis A vaccine (Avaxim, VAQTA, Havrix) is given as an injection: a single dose will give protection for up to a year, while a booster 12 months later will provide a subsequent 10 years of protection.
Infected blood, contaminated needles and sexual intercourse can all transmit hepatitis B. It can cause jaundice, and affects the liver, occasionally causing liver failure. All travellers should make this a routine vaccination. (Many countries now give hepatitis B vaccination as part of routine childhood vaccination.) A course will give protection for at least five years, and can be given over four weeks or six months.
Spread through the bite of an infected sand fly, leishmaniasis can cause a slowly growing skin lump or ulcer. It may develop into a serious life-threatening fever usually accompanied by anaemia and weight loss. Sand fly bites should be avoided whenever possible. Infected dogs are also carriers. Leishmaniasis is present in Iran, Iraq, Israel and the Palestinian Territories, Jordan, Lebanon, Syria and Turkey.
The prevalence of malaria varies throughout the Middle East. Many areas are considered to be malaria free, while others have seasonal risks. The risk of malaria is minimal in most cities; however, check with your doctor if you are considering travelling to any rural areas. It is important to take antimalarial tablets if the risk is significant. For up-to-date information about the risk of contracting malaria in a specific country, contact your local travel health clinic.
Middle East Respiratory Syndrome (MERS)
Middle East Respiratory Syndrome (MERS) is present throughout the Middle East and causes serious respiratory problems, with children and the elderly particularly at risk. MERS can be fatal in approximately one-third of cases. The illness can be passed from sick animals (particularly camels) to people – always wash your hands thoroughly and immediately after being in contact with camels – although it is not understood how the virus passes from one person to another. Symptoms include fever, cough, shortness of breath and (sometimes) pneumonia. Other possible symptoms include muscle pain, diarrhoea, vomiting and nausea.
Generally spread through contaminated food and water, polio is present, though rare, throughout the Middle East. It is one of the vaccines given in childhood and should be boosted every 10 years, either orally (a drop on the tongue), or as an injection. Polio may be carried asymptomatically, although it can cause a transient fever and, in rare cases, potentially permanent muscle weakness or paralysis.
Spread through bites or licks on broken skin from an infected animal, rabies (present in all countries of the Middle East) is fatal. Animal handlers should be vaccinated, as should those travelling to remote areas where a reliable source of postbite vaccine is not available within 24 hours. Three injections are needed over a month. If you have not been vaccinated you will need a course of five injections starting within 24 hours or as soon as possible after the injury. Vaccination does not provide you with immunity, it merely buys you more time to seek appropriate medical treatment.
Rift Valley Fever
This haemorrhagic fever, which is found in Egypt, is spread through blood or blood products, including those from infected animals. It causes a flu-like illness with fever, joint pains and occasionally more serious complications. Complete recovery is possible.
Otherwise known as bilharzia, this is spread through the freshwater snail. It causes infection of the bowel and bladder, often with bleeding. It is caused by a fluke and is contracted through the skin from water contaminated with human urine or faeces. Paddling or swimming in suspect freshwater lakes or slow-running rivers should be avoided. There may be no symptoms. Possible symptoms include a transient fever and rash, and advanced cases of bilharzia may cause blood in the stool or in the urine. A blood test can detect antibodies if you have been exposed and treatment is then possible in specialist travel or infectious-disease clinics. Be especially careful in Egypt, Iran, Iraq and Syria.
Tuberculosis is spread through close respiratory contact and occasionally through infected milk or milk products. BCG vaccine is recommended for those likely to be mixing closely with the local population. It is more important for those visiting family or planning on a long stay, and those employed as teachers and health-care workers. TB can be asymptomatic, although symptoms can include coughing, weight loss or fever months or even years after exposure. An X-ray is the best way to confirm if you have TB. BCG gives a moderate degree of protection against TB. It causes a small permanent scar at the site of injection, and is usually only given in specialised chest clinics. As it’s a live vaccine it should not be given to pregnant women or immunocompromised individuals. The BCG vaccine is not available in all countries.
Typhoid is spread through food or water that has been contaminated by infected human faeces. The first symptom is usually fever or a pink rash on the abdomen. Septicaemia (blood poisoning) may also occur. Typhoid vaccine (typhim Vi, typherix) will give protection for three years. In some countries, the oral vaccine Vivotif is also available.
Yellow fever vaccination is not required for any areas of the Middle East. However, the mosquito that spreads yellow fever has been known to be present in some parts of the region. It is important to consult your local travel health clinic as part of your predeparture plans for the latest details. Any travellers from a yellow fever endemic area (eg parts of sub-Saharan Africa) will need to show proof of vaccination against yellow fever before entry.
Heat exhaustion occurs after heavy sweating and excessive fluid loss with inadequate replacement of fluids and salt. It is particularly common in hot climates when taking unaccustomed exercise before full acclimatisation. Symptoms include headache, dizziness and tiredness. Dehydration is already happening by the time you feel thirsty – aim to drink sufficient water so that you produce pale, diluted urine. The treatment of heat exhaustion consists of fluid replacement with water or fruit juice or both, and cooling by cold water and fans. The treatment of the salt-loss component consists of taking in salty fluids (such as soup or broth), and adding a little more table salt to foods than usual.
Heat stroke is much more serious. This occurs when the heat-regulating mechanism in the body breaks down. An excessive rise in body temperature leads to sweating ceasing, irrational and hyperactive behaviour, and eventually loss of consciousness and death. Rapid cooling by spraying the body with water and fanning is an ideal treatment. Emergency fluid and electrolyte replacement by intravenous drip is usually also required.
Insect Bites & Stings
Mosquitoes may not carry malaria but can cause irritation and infected bites. Using DEET-based insect repellents will prevent bites. Mosquitoes also spread dengue fever.
Bees and wasps only cause real problems to those with a severe allergy (anaphylaxis). If you have a severe allergy to bee or wasp stings you should carry an adrenaline injection or similar.
Scorpions are frequently found in arid or dry climates. They can cause a painful sting, which is rarely life threatening.
Bed bugs are often found in hostels and cheap hotels. They lead to very itchy lumpy bites. Spraying the mattress with an appropriate insect killer will do a good job of getting rid of them.
Scabies are also frequently found in cheap accommodation. These tiny mites live in the skin, particularly between the fingers. They cause an intensely itchy rash. Scabies is easily treated with lotion available from pharmacies.
Do not walk barefoot or stick your hand into holes or cracks. Half of those bitten by venomous snakes are not actually injected with poison (envenomed). If bitten by a snake, do not panic. Immobilise the bitten limb with a splint (eg a stick) and apply a bandage over the site using firm pressure, similar to a bandage over a sprain. Do not apply a tourniquet, or cut or suck the bite. Get the victim to medical help as soon as possible so that antivenene can be given if necessary.
To prevent diarrhoea, avoid tap water unless it has been boiled, filtered or chemically disinfected (with iodine tablets). Eat only fresh fruits or vegetables if cooked or if you have peeled them yourself, and avoid dairy products that may contain unpasteurised milk. Buffet meals are risky, as food should be piping hot; meals freshly cooked in front of you in a busy restaurant are more likely to be safe.
If you develop diarrhoea, be sure to drink plenty of fluids, preferably an oral rehydration solution containing salt and sugar. A few loose stools don’t require treatment but, if you start having more than four or five stools a day, you should start taking an antibiotic (usually a quinolone drug) and an antidiarrhoeal agent (such as loperamide). If diarrhoea is bloody, persists for more than 72 hours, or is accompanied by fever, shaking chills or severe abdominal pain you should seek medical attention.
Many locals don’t drink the tap water, and we recommend that you follow their lead. If you do decide to risk the local water, the safest places to do so are in Israel, Turkey and the Gulf countries. Don’t even think of drinking from the tap in Egypt, the Palestinian Territories or Lebanon. Cheap bottled water is readily available throughout the region, though consider the impact on the environment.
Travelling with Children
All travellers with children should know how to treat minor ailments and when to seek medical treatment. Make sure children are up to date with the routine vaccinations, and discuss possible travel vaccinations well before departure as some are not suitable for children aged under one year old.
In hot, moist climates any wound or break in the skin may lead to infection. The area should be cleaned and then kept dry and clean. Remember to avoid potentially contaminated food and water. If your child is vomiting or experiencing diarrhoea, lost fluid and salts must be replaced. It may be helpful to take rehydration powders for reconstituting with boiled water. Ask your doctor about this.
Children should be encouraged to avoid dogs or other mammals because of the risk of rabies and other diseases. Any bite, scratch or lick from a warm blooded, furry animal should immediately be thoroughly cleaned. If there is any possibility that the animal is infected with rabies, immediate medical assistance should be sought.
Emotional stress, exhaustion and travelling through different time zones can all contribute to an upset in the menstrual pattern. If using oral contraceptives, remember some antibiotics, diarrhoea and vomiting can stop the pill from working and lead to the risk of pregnancy – it's safest to take other forms of contraception with you.
Emergency contraception is most effective if taken within 24 hours after unprotected sex. The International Planned Parent Federation (www.ippf.org) can advise about the availability of contraception in different countries.
Tampons and sanitary towels are not always available outside of major cities in the Middle East.
Travelling during pregnancy is usually possible, but there are important things to consider. Have a medical check-up before embarking on your trip. The most risky times for travel are during the first 12 weeks of pregnancy, when miscarriage is most likely, and after 30 weeks, when complications such as high blood pressure and premature delivery can occur. Most airlines will not accept a traveller after 28 to 32 weeks of pregnancy, and long-haul flights in the later stages can be very uncomfortable. Antenatal facilities vary greatly between countries in the Middle East, and you should think carefully before travelling to a country with poor medical facilities or where there are major cultural and language differences compared with home. Taking written records of the pregnancy, including details of your blood group, is likely to be helpful if you need medical attention while away. Ensure your insurance policy covers pregnancy, delivery and postnatal care, but remember insurance policies are only as good as the facilities available.